Willow View Gardens Memory Care & Assisted Living.

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced visit to Willow View Gardens. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 130 non-ambulatory residents of which 50 may be bedridden. Facility has an approved hospice waiver for 50 residents and there are no residents on hospice during today's visit. Administrator Alma Espinal has an administrator certificate expiring on 04/01/2026. LPAs Lyman and Arias along with Administrator toured the facility at 8:28 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility consists of two stories including a library, bistro, cinema room and hair salon. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F and 110.3 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances are operational during today's visit. Toxins are secured in a closet. Smoke detectors and carbon monoxide detectors are tested in-house monthly and fire/ sprinkler inspections are conducted by a third party. Fire extinguishers were fully charged. Facility conducts monthly emergency drills with the last drill conducted on 10/20/2025. LPAs observed ample emergency food and water. Outside grounds were toured. LPAs observed multiple outside patio areas including a smoking area. There is ample outdoor shaded seating for residents.. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. continued ON LIC 809C DATED 11/18/2025 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 First aid kit contained all required items including tweezers, scissors and thermometer. Facility provides activities in the form of music, art and puzzles. LPAs reviewed select resident files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. LPA to return at a later date to continue the annual inspection. Exit interview conducted and a copy of this report was left at the facility.

has improved, and they have no issues. Staff interviewed said there were no problems with mail. The mail is at the front desk and only staff have access to the mail. They file the mail by room number and the residents’ mail are locked and secure. ED Espinal said only Memory Care does not receive their mail. She stated packages are given to the residents at the end of the day and they never deny any residents mail service. It is the responsibility of the residents to ask and get their mail. Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegation staff did not provide mail to resident in care has been determined to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited at this time and an exit interview was conducted with Executive Director Alma Espinal. A copy of the report was provided to the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 handle their own medication, they can read, they administer their own insulin, so they want to request the doctor if they can handle their own medication. All staff agree that there is no mismanagement of medication. They try their best to give the medication on time but of course there is a delay at times because there are things that arise during their shift, like helping another staff assist with another residents and emergencies. One staff member stated they follow doctor’s order, and they have a lot of in-service trainings for medication and they use a MAR to document medication dosage. Nurse Consultant, Amie Pangilinan which is similar to a Health Service Director position, stated that she monitors her MedTech staff and so far, there are no medication errors. Her in-service training focuses on logging medication refusals and addressing questions about medication that MedTech staff have. It was alleged that staff did not prevent resident from harming another resident in care. LPA spoke to residents and eight out eight residents, although a few of them have never seen residents fight, they all have similarly agreed that staff at the facility try their best to prevent resident from harming another resident or further escalation. Some residents have seen staff stepping in and telling them to stop. R1 stated during a bingo game another resident got upset and hit their hand. The staff did intervene and later the resident who hit R1’s hand came to apologize for what had happened because of the staff intervention. All staff interviewed have agree that when they see residents arguing they try to de-escalate the situation. One staff said they try to talk to them to calm them down and separate them. Then the staff offers solutions to the resident, like asking if the resident can sit at this table for the time being. All staff feel they are doing a good job of protecting residents. It was alleged that staff did not provide housekeeping services to residents in care in a timely manner. Eight of eight residents interviewed said that facility provides adequate housekeeping services to them in a timely manner. The residents interviewed have stated that they thoroughly clean their rooms once a week on specific days. The bed linens are changed weekly, and staff do their laundry. Granted that most of the time staff are busy, when housekeeping requests are made, the residents mention they try their best to complete their requests. R1 stated that the staff missed wiping the dust underneath their mattress, but overall, they did a good job. All staff LPA interviewed as well agree that they try their best to clean and keep up with the resident’s housekeeping request, despite they can be demanding. One of the housekeepers who clean R1’s room said that R1 appreciates them cleaning their room and on days when she is not there she gets upset at (Complaint Report continued on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 other staff because they do not clean their room like the housekeeper that cleans their room regularly. Staff have all stated that resident rooms have a scheduled day where they clean their room. They clean the room as needed for spills, accidents, and soiled bedding. It was alleged that staff did not safeguard resident's personal items. Per interviews with residents, seven out of eight residents have felt their personal belongings were safeguarded by the staff. They never had issues with anyone stealing their personal belongings. R1 stated they left money on their night stand, and it was still there. R1 stated staff are honest, hard-working people who would never risk their jobs to steal something from residents and protect them from other residents. All staff interviewed have similarly acknowledge that they do their best to safeguard residents’ personal belongings. Two staff interviewed would make sure that the residents’ doors were closed. They would question any resident who is going into someone else’s room and redirect them out of the resident’s room. Often residents misplaced their stuff. They would say their stuff had been stolen and at the end of the day they would find it later because they do not remember where it was or it was misplaced. It was alleged that staff did not provide toileting assistance to resident in care in a timely manner. Per investigation, eight of eight residents interviewed feel the facility does a great job in assisting resident with toileting. Some residents interviewed say they do not need toileting assistance but however they said they never heard of any of issues with toileting assistance amongst other residents living at the facility. One resident spoken said one time they were sick the staff did a great job in assisting them to the restroom when they needed help. Another resident said they help them change their diapers and their clothes with no problem. R1 stated that the staff come right away to assist their roommate with toileting services. Just at night time, due to staff shortages it is a bit longer response. All staff interviewed have said that they do their best to help residents with toileting assistance. At times they are busy helping a lot of residents, but they do their best and change their diapers and clean them up. One staff member said unfortunately mishaps happen because residents have diarrhea, again they try their best to assist residents with their toileting needs. It was alleged that staff spoke inappropriately to resident in care. All residents interviewed unanimously agree they have never been spoken to inappropriately. They were treated with respect by the facility staff. R1 said the staff have never even raised their voices at them. R1 has seen residents treat staff disrespectfully. All staff interviewed have all agreed that they have always treated residents with respect and are careful with what they say to residents. One staff interviewed stated that they treat the residents like family just like how (Complaint Report continued on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 they would treat or talk to their own mother because the staff has had experience taking care of their mother who had Alzheimer’s for ten years. It was alleged that staff did not implement proper hand hygiene procedures. Per interviews with residents, seven out of eight residents felt that the staff implemented proper hand hygiene because they saw the staff wearing gloves most of the time especially when handling food, when cleaning their room. Residents have seen the staff wash their hands routinely. However, one resident, R1 has seen a staff who helped in the kitchen use their bare hands to scoop the ice. R1 acknowledge that to the staff and refused the ice. All the staff interviewed have said they do practice proper hand hygiene, they wash their hands and wear gloves, when necessary, especially cleaning and handling with food. LPA interviewed one of the kitchen staff and said when they handle or serve food and take out the trash they always wear gloves. They said they would never use their bare hands to scoop ice because there are two ice scoopers in the kitchen for them to use to scoop ice for the residents. They wash their hands, and they have convenient soap dispenser and sink to wash their hands. They are afraid to get sick from residents and protect their health by wearing gloves and washing their hands frequently. During all visits, LPA has observed staff such as caregivers have gloves on. LPA also observed all kitchen staff wearing and using gloves in the kitchen as well. Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegations that facility staff mismanaged resident's medications, staff did not prevent resident from harming another resident in care, staff did not provide housekeeping services to resident in care in a timely manner, staff did not safeguard resident's personal items, staff did not provide toileting assistance to resident in care in a timely manner, staff spoke inappropriately to resident in care, and staff did not implement proper hand hygiene procedures has been determined as UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. No deficiencies cited at this time and an exit interview was conducted with Executive Director Alma Espinal. A copy of the report was provided to the facility.

Continued from LIC9099-A A review of Santa Ana Police records shows that R1 stated to police on 5/8/2024 that “R1 has not had any thefts. R1 was allowed to change locks to prevent anyone from coming into R1’s room and was confused as to why an officer was there” Based on interviews, photographs, room inspection, and police reports, due to conflicting information, LPM is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of the report was sent to Alma Espinal via email for signature.

LPA interviewed three residents who stated having items go missing from time to time with sometimes the items would be found or misplaced. All three could not confirm if missing items had been stolen or misplaced. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.

On September 11, 2024, R1 was found by Staff 1 (S1) at approximately 1 PM laying on their bedroom floor. S1 reported they had heard R1 calling for help prompting their response. Upon finding R1, facility staff sought emergency medical services. R1 reported they were attempting to reach for their walker when they fell. S1 reported last observing R1 at 12PM, approximately an hour earlier, when they had passed out medications. Upon being admitted to Norwalk Community Hospital, R1 was diagnosed with facial contusions, knee abrasions and forehead hematoma. R1 reported to hospital staff they had fallen after reaching for a napkin. Due to inconsistency in R1’s report and injuries observed, Santa Ana Police arrived to speak with R1. Per Santa Ana Police report, R1’s injuries appeared consistent with injuries sustained from a fall. R1 reported being beaten by “four women” but was unable to provide further elaboration. The Department attempted a separate interview with R1 but was unable to due to R1’s cognitive decline. R1 did not appear oriented to time and space. Interviews with four of four staff reported R1 was independent prior to fall and received hourly to bi-hourly checks. Staff reported being aware R1 was a fall risk. The facility provided R1 with a fall matt and a call light to ask for assistance when needed. Interviews with R1’s nurse practitioner revealed no concerns of neglect. Per interview with R1’s responsible party, no concerns with R1’s care were expressed. Based on interviews conducted and records reviewed, the allegations that Resident sustained unexplained injuries due to lack of supervision and Resident sustained unwitnessed fall due to lack of supervision is deemed to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. This agency has investigated this complaint. An exit interview was conducted and a copy of this report and confidential names list was provided to facility representative.

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809 D on 11/06/2024 LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. During today's visit, medications are secured. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87464(f)(4) pertaining to Basic Services has been cleared. Licensee provided proof of correction. *Deficiency cited under Title 22 Regulation 87411(f) pertaining to TB testing has been cleared. Licensee provided proof of correction. Licensee has been advised to remain in compliance with items previously cited at the facility. Exit interview conducted and a copy of this report was left at the facility.

Licensing Program Analysts (LPAs) Kimberly Lyman and Sam Haddadin conducted an unannounced case management visit to follow up on an incident report submitted on 05/31/2024. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 05/29/2024 indicated Resident 1 (R1) was sent out on a 5150 psychiatric evaluation after allegedly making threats to kill everyone in the facility. Resident was evaluated by psychiatrist and referred for the hold. Resident was sent to LA Downtown Medical Center. Resident has a history of bi-polar, depression, paranoia and anxiety. Resident has not returned to the facility. LPAs toured the facility and observed residents relaxing and eating lunch. Facility appears clean, safe and sanitary during today's visit. Exit interview conducted and a copy of this report was left at the facility.

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809 D on 04/08/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87458(a) regarding Medical Assessment has been cleared. Licensee provided proof of medical assessment for Resident 1. Licensee has complied with the POC. Licensee has been advised to remain in compliance with items previously cited at the facility. Exit interview conducted and a copy of this report was left at the facility.

unrelated to the fall that was observed. Family confirms no injuries noted on resident and facility documents confirm the reason for the resident's send out. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.

Resident did not return to facility after hospitalization. Four out of four staff indicate the resident had a history of losing keys as the resident would leave the facility for weeks at a time. The resident's keys were replaced timely per all staff interviewed and LPA observed the key making machine on-site at the facility as well as all the master keys to be utilized. Facility provides activities to residents and LPA observed residents participating in activities on multiple occasions. Activities are provided in the way of bingo, music therapy and cooking classes and three out of three residents interviewed confirmed activities. Four out of four staff interviewed stated that resident would leave the facility for weeks at a time or would leave in the morning to hang out outside the local 7-11. Staff would not deny the resident to leave facility. Physician report dated 02/23/2023 indicated resident was allowed to leave the facility unassisted. Preplacement appraisal as well as appraisal needs and services indicate resident leaves facility daily. Based on record review and interviews conducted, the allegations are deemed unfounded, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to Administrator.

Six put of seven residents interviewed denied communication issues with staff and LPA did not experience any communication issues with staff during visits. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.

employed as the full time Activity Director. Two out of two staff deny the error as well as Administrator. Facility staffing schedule indicates the following: Four caregivers/ 1 med tech on 1st shift, Four caregivers/ 1 med tech on second shift and 1 caregiver/ 1 med tech for NOC shift. Six out of six residents and two out of two staff state staffing levels have increased in the last few months. Administrator indicates hiring new staff. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Therefore, the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to Administrator.